Healthcare Provider Details

I. General information

NPI: 1376298927
Provider Name (Legal Business Name): MATTHEW S HOVELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2022
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 N ROGER ST
KIMBERLY WI
54136-1228
US

IV. Provider business mailing address

322 N ROGER ST
KIMBERLY WI
54136-1228
US

V. Phone/Fax

Practice location:
  • Phone: 920-858-8490
  • Fax:
Mailing address:
  • Phone: 920-858-8490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: